Contrast-Enhanced Ultrasonography in Diagnosing Intravascular Large B-Cell Lymphoma Infiltrating Liver Sinusoids

BACKGROUND Intravascular large B-cell lymphoma (IVLBCL) is a rare extranodal large B-cell lymphoma characterized by the selective growth of lymphoma cells within vasculature. This presents a diagnostic challenge due to non-specific symptoms and lack of tumor formation. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) provides useful information in diagnosing FDG-avid lymphoma, but is not specific to  IVLBCL. Contrast-enhanced ultrasonography (CEUS) is useful in evaluating focal liver lesions; however, its efficacy in diagnosing IVLBCL involving the liver remains unknown. CASE REPORT We report the case of an 83-year-old woman presenting with fever, pancytopenia, liver dysfunction, and elevated LD and soluble interleukin-2 receptor levels. PET-CT showed multiple uptake lesions in the liver. We performed CEUS with Sonazoid® to evaluate the mass-like lesions; however, no nodular lesions were observed in B mode images. Systemic enhancement was seen in the early phase but no defect was observed in the post-vascular phase. The latter finding suggested preserved Kupffer cells function, excluding tumor-forming lymphoma and liver metastases. Suspecting IVLBCL, we performed a bone marrow examination, which showed sinusoidal infiltration of large neoplastic cells positive for CD20. The patient's condition deteriorated rapidly and she died 2 days after the examination. Autopsy revealed diffuse infiltration of lymphoma cells into liver sinusoids with preserved Kupffer cells, leading to the diagnosis of IVLBCL. CONCLUSIONS Our case shows that CEUS can distinguish IVLBCL from mass-forming lymphoma based on the absence of a defect in the post-vascular phase in a patient with clinically and radiographically suspected lymphoma involving the liver. This can assist clinicians to select appropriate lesions for biopsy.

Noninvasive Visualization of Tumor Blood Vessels within Hepatocellular Carcinoma by Application of Superb Microvascular Imaging to Contrast-Enhanced Ultrasonography

The combination or sequential use of systemic therapies, such as lenvatinib and locoregional therapies, can improve the curability rate of hepatocellular carcinoma. This is based on the notion that lenvatinib remodels abnormal tumor vessels into normal vessels, potentially enhancing the efficacy of locoregional therapies. In this case report, we achieved noninvasive visualization of tumor blood vessels by applying superb microvascular imaging (SMI) to contrast-enhanced ultrasonography (CEUS). A man in his 80s with a borderline resectable hepatocellular carcinoma received preoperative therapy using lenvatinib. The patient achieved a complete response after lenvatinib therapy, underwent hepatectomy, and maintained a cancer-free status. CEUS and SMI revealed a decrease in tumor blood vessels at 1 week after lenvatinib administration and a decrease in tumor perfusion at 2 weeks. Although CEUS alone is adequate for noninvasive real-time evaluation of tumor perfusion, it is not sufficient to achieve accurate assessments of tumor blood vessels. We performed a noninvasive time-course evaluation of vascular normalization after lenvatinib administration by applying SMI. The evaluation of vascular normalization with lenvatinib therapy using CEUS and SMI can support the decision to proceed to conversion therapies.

Percutaneous ablation of colorectal liver metastases: a comparison between the outcomes of grayscale US guidance and Sonazoid CEUS Kupffer phase guidance using propensity score matching

PURPOSE

To assess the utility of Sonazoid contrast-enhanced ultrasound (CEUS) for guiding percutaneous microwave ablation (MWA) for colorectal liver metastases (CRLMs).

MATERIALS AND METHODS

The medical records of patients who had undergone ultrasound (US)-guided percutaneous MWA between July 2020 and June 2022, were reviewed. Propensity score matching (PSM) with a ratio of 1:1 was used to balance the potential bias between the grayscale US-guided and Sonazoid CEUS-guided groups. Local tumor progression (LTP), intrahepatic recurrence (IR), and complication rates were compared between the two groups.

RESULTS

Of 252 patients enrolled, 247 achieved complete ablation, and the technical effectiveness was 98.0% (247/252). Of these 247 patients, 158 were in the grayscale US-guided group and 89 in the Sonazoid CEUS-guided group. The median follow-up period was 14.6 months. After PSM, there were no significant differences in LTP, IR, or complication rates between the two groups (p = 0.100, p = 0.511, p > 0.99, respectively). Multivariate analysis identified tumor size ≥ 3 cm (hazard ratio [HR], 7.945; 95% CI, 2.591-24.370; p < 0.001), perivascular (HR, 2.331; 95% CI, 1.068-5.087; p = 0.034), and tumor depth > 8 cm (HR, 3.194; 95% CI, 1.439-7.091; p = 0.004) as significant factors associated with LTP. For tumors with poor vision on grayscale US, Sonazoid CEUS-guided ablation achieved a better LTP rate than grayscale US-guided ablation (3.7% vs.14.8%, p = 0.032).

CONCLUSION

For tumors with poor vision on grayscale US, Sonazoid CEUS guidance is recommended for better local tumor control.

Comparison of modified CEUS LI-RADS with sonazoid and CT/MRI LI-RADS for diagnosis of hepatocellular carcinoma

AIM

To compare the diagnostic performance based on the modified CEUS Liver Imaging Reporting and Data System (LI-RADS), which includes Kupffer-phase findings as a major imaging feature, with that of CT and MRI (CT/MRI) LI-RADS for liver nodules in patients at high risk of HCC.

METHODS

A total of 120 patients with 120 nodules were included in this retrospective study. The median size of the lesions was 20.0 mm (interquartile range, 14.0-30.8 mm). Of these lesions, 90.0% (108 of 120) were confirmed as HCCs, 6.7% (8 of 120) were intrahepatic cholangiocarcinomas, 1.7% (2 of 120) were metastases, and 1.7% (2 of 120) were dysplastic nodules. All nodules were diagnosed histopathologically. Each nodule was categorized according to the modified CEUS LI-RADS and CT/MRI LI-RADS version 2018. The diagnostic performance and inter-modality agreement of each criterion was compared.

RESULTS

The inter-modality agreement for the modified CEUS LI-RADS and CT/MRI LI-RADS was slight agreement (kappa = 0.139, p = 0.015). The diagnostic accuracies of HCCs for the modified CEUS LR-5 and CT/MRI LR-5 were 70.0% (95% confidence interval [CI]: 61.0%, 78.0%) versus 70.8% (95% CI: 61.8%, 78.8%) (p = 0.876), respectively. The diagnostic accuracies of non-HCC malignancies for the modified CEUS LR-M and CT/MRI LR-M were 84.2% (95% CI: 76.4%, 90.2%) versus 96.7% (95% CI: 91.7%, 99.1%) (p = 0.002), respectively.

CONCLUSIONS

The diagnostic performance for HCCs on the modified CEUS LR-5 and CT/MRI LR-5 are comparable. In contrast, CT/MRI LR-M has better diagnostic performance for non-HCC malignancy than that of the modified CEUS LR-M.

Utility of contrast-enhanced harmonic endoscopic ultrasonography for predicting the prognosis of pancreatic neuroendocrine neoplasms

BACKGROUND AND AIMS

Pancreatic neuroendocrine neoplasms (PanNENs), including Grade 1 (G1) or G2 tumors, can have a poor prognosis. This study investigated the value of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for predicting the prognosis of PanNENs.

METHODS

This single-center, retrospective study included 47 consecutive patients who underwent CH-EUS and were diagnosed with PanNEN by surgical resection or EUS-guided fine needle aspiration between December 2011 and February 2016. Patients were divided into aggressive and non-aggressive groups according to the degree of clinical malignancy. CH-EUS was assessed regarding its capacity for diagnosing aggressive PanNEN, the correspondence between contrast patterns and pathological features, and its ability to predict the prognosis of PanNEN.

RESULTS

There were 19 cases of aggressive PanNEN and 28 cases of non-aggressive PanNEN. The aggressive group included three G1, four G2, three G3 tumors, three mixed neuroendocrine non-neuroendocrine neoplasms, and six neuroendocrine carcinomas. CH-EUS was superior to contrast-enhanced computed tomography for the diagnosis of aggressive PanNEN (P < 0.001): hypo-enhancement on CH-EUS was an indicator of aggressive PanNEN, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 94.7%, 100%, 100%, 96.6%, and 97.9%, respectively. Among G1/G2 PanNENs, cases with hypo-enhancement on CH-EUS had a poorer prognosis than those with hyper/iso-enhancement (P = 0.0009). Assessment of 36 resected specimens showed that hypo-enhancement on CH-EUS was associated with smaller and fewer vessels and greater degree of fibrosis.

CONCLUSION

Contrast-enhanced harmonic endoscopic ultrasonography may be useful for predicting the prognosis of PanNENs.

A simplified method to quantitatively predict the effect of lenvatinib on hepatocellular carcinoma using contrast-enhanced ultrasound with perfluorobutane microbubbles

Contrast-enhanced computed tomography (CECT) is generally used to evaluate the response to treatment of hepatocellular carcinoma (HCC); however, CECT is unsuitable for the early prediction of therapeutic effects and frequent monitoring. We aimed to investigate the usefulness of our simplified method for the quantification of tumor vascularity using contrast-enhanced ultrasound (CEUS) with perfluorobutane microbubbles [Sonazoid^® (GE Healthcare, Oslo, Norway)] to predict the therapeutic effect of lenvatinib. Among the 13 patients studied, nine who had more than a 20% reduction in tumor vascularity within 2 weeks of starting treatment experienced complete response or partial response at 8-12 weeks as assessed by CECT. In contrast, three patients without reductions and one patient with only a slight decrease in tumor vascularity had a poor response to lenvatinib. Quantitative assessment of tumor vascularity by our simplified CEUS-based method could be a useful predictor of therapeutic responses to lenvatinib in patients with HCC.

Role of contrast-enhanced ultrasound with Sonazoid in management of small testicular Leydig cell tumours: A case report with literature review

Small testicular solid lesions are discovered accidentally due to the extensive use of ultrasound in urology and andrology. Early differentiation between benign and malignant testicular neoplasms is crucial for the determination of treatment options, especially for sub-centimetre lesions. We report a case of a male patient with an incidental discovery of a small testicular lesion on ultrasonography with the chief complaint of left testicular discomfort. The blood-flow distribution and microbubble dynamics in the lesion were evaluated through contrast-enhanced ultrasound using Sonazoid intravenous bolus injection, the rapid and intense enhancement pattern tended to be testicular Leydig cell tumour. Through testicular-sparing surgery, the lesion was excised, and benign testicular Leydig cell tumour was confirmed by post-operative pathology and immunohistochemical pathology. No sign of recurrence or metastasis was detected during follow-up.

Use of Contrast-Enhanced Ultrasound with Sonazoid for Evaluating the Radiotherapy Efficacy for Hepatocellular Carcinoma

Radiotherapy is one of the available curative therapies for hepatocellular carcinoma (HCC). We investigate the use of contrast-enhanced ultrasound using Sonazoid (SCEUS) in evaluating the efficacy of radiotherapy for HCC. We enrolled 59 patients with 59 HCCs in this retrospective study. Tumor size and tumor vascularity were evaluated using SCEUS before and 1, 3, 7, 10, and 13 months after radiotherapy. The median follow-up period was 44.5 months (range: 16–82 months). Of the HCCs, 95% (56/59) had no local recurrence, while 5% (3/59) did. At 13 months after radiotherapy, in cases with no local recurrence, SCEUS showed a reduction in tumor vascularity in all cases, while tumor size reduction (>30% reduction, compared with pre-radiotherapy) was observed in 82.1% (46/56). In all three cases of local recurrence, vascularity and tumor size reduction were not observed during the follow-up period and residual HCCs were demonstrated pathologically. Compared with cases with local recurrence, tumor size reduction and reduction in tumor vascularity (p < 0.001) were significantly greater in cases with no local recurrence at 13 months after radiotherapy. SCEUS may be useful in evaluating radiotherapy efficacy for HCC.

Clinical significance of performing Sonazoid-based contrast-enhanced ultrasonography before ablation of uterine fibroids by high-intensity focused ultrasound: A preliminary cohort study

High-intensity focused ultrasound (HIFU) is effective for the ablation of uterine fibroids. However, no research has indicated whether HIFU ablation of uterine fibroids might be improved by application of contrast-enhanced ultrasonography (CEUS) with Sonazoid as a contrast agent. This study aimed to assess the clinical significance of Sonazoid-based CEUS 30 minute before HIFU ablation of uterine fibroids.This retrospective cohort study included Asian patients with solitary uterine fibroids who were treated with HIFU at Seoul HICARE Clinic (South Korea; n = 34) and the Second Affiliated Hospital of Chongqing Medical University (China; n = 30) between August 1, 2017, and October 31, 2017. The patients in Seoul underwent Sonazoid-based CEUS 30 minute before HIFU. All the patients received contrast-enhanced magnetic resonance imaging to diagnose uterine fibroids. The ablation results were evaluated 1 day after HIFU by contrast-enhanced magnetic resonance imaging or Sonazoid-based CEUS.All the patients were successfully treated with HIFU. The CEUS+HIFU group had lower values for sonication power, treatment time, sonication time, total energy applied, and energy efficiency factor compared with HIFU alone group (P < .001). There were no major adverse events after ablation therapy in either group. The incidence of post-procedure sacrococcygeal pain was lower in the CEUS+HIFU group than that in the HIFU alone group (P = .045), while the incidences of all other intraoperative and postoperative adverse events were similar between the 2 groups.Our findings suggest that Sonazoid-based CEUS before HIFU may enhance the ablation of uterine fibroids.

Utility of contrast-enhanced ultrasound in differential diagnosis of adrenal tumors in dogs

This prospective case study aimed to clarify the clinical significance of contrast-enhanced ultrasound (CEUS) for the differential diagnosis of canine adrenal tumors. Forty-three client-owned dogs with adrenal tumors were included. All dogs underwent CEUS, which was evaluated qualitatively and quantitatively. The peak signal intensity (PI), time to peak signal intensity (TPI), mean transit time (MTT), upslope, and downslope were calculated for each time-intensity curve. The histopathological diagnosis of each resected mass was compared with the CEUS findings and parameters. Enhancement distribution, vascularity, tortuous nourishing vessels, enhancement pattern, and late-phase enhancement did not differ significantly between adrenal cortical adenoma (CA), adenocarcinoma (CAC), and pheochromocytoma (PHEO) in qualitative assessment. In PHEO, the TPI was significantly more rapid compared with that in CA (P=0.0287) and CAC (P=0.0404). The MTT in PHEO was significantly shorter than that in CA (P=0.0016) and CAC (P=0.0003). Upslope in PHEO was larger than that in CAC (P=0.0406). Downslope in PHEO was significantly larger than that in CA (P=0.0048) and CAC (P=0.0018). A receiver operating characteristic curve analysis demonstrated that the area under the MTT curve yielded 0.91 for distinguishing PHEO from adrenocortical tumors in dogs; an MTT cut-off value less than 6,225 msec yielded a sensitivity of 69%, specificity of 94%, and likelihood ratio of 12.46. CEUS appears to be clinically applicable for the differential diagnosis between cortical and medullary origins of primary adrenal tumors in dogs.

The Efficacy of Sonazoid-enhanced Ultrasonography in Decision-making for Liver Abscess Treatment

Objective The usefulness of contrast-enhanced ultrasonography (CEUS) for making decisions in the treatment of liver abscess is unknown. Methods We evaluated the internal blood flow in the arterial-predominant phase by CEUS using Sonazoid^® in 21 patients. The stain area rate was evaluated in maximum parting plane of abscess in CEUS. Patients were divided into two groups: the vascular phase enhancement (VE) group, in which ≥50% of the abscess cavity was enhanced (12 patients), and the vascular phase non-enhancement (VNE) group, in which <50% of the abscess cavity was enhanced (9 patients). The rate of patients who were cured by conservative treatment alone was examined in both groups. The defect rate of all liver abscesses in the post-vascular phase was also evaluated. Results In the VE group, improvement by conservative treatment alone was obtained in 11 out of 12 patients (91.7%), while in the VNE group, improvement by conservative treatment alone was obtained in only 1 out of 9 patients (11.1%), a significant difference (p<0.001). In the VE group, one patient did not improve with conservative treatment alone because the abscess ruptured near the liver surface. In the VE group, the abscess size was smaller than in the VNE group. By examining the defect rate in the post-vascular phase, it was found that 16 out of 21 patients (76.2%) showed 71% or more defects. Conclusion The enhancement rate in the arterial-predominant phase of CEUS was considered useful for determining the treatment approach for liver abscess.

Visibility of focal liver lesions: Comparison between kupffer phase of CEUS with sonazoid and hepatobiliary phase of gadoxetic acid-enhanced MRI

BACKGROUND

To investigate the agreement between Kupffer phase of Sonazoid contrast-enhanced sonography (CEUS) and hepatobiliary phase of gadoxetic acid-enhanced MRI in the evaluation of focal liver lesions (FLLs).

METHODS

One hundred fifty-four FLLs in 154 patients who underwent both Sonazoid CEUS and gadoxetic acid-enhanced liver MRI were included in this retrospective study. FLL visibility on the Kupffer-phase images was graded as one (invisible or isoenhancing), two (vaguely visible or vaguely hypoenhancing), or three (clearly visible or clearly hypoenhancing), and that on the hepatobiliary-phase images of MRI was graded as one (invisible or hyper/isointense), two (vaguely visible or weakly hypointense), or three (clearly visible or strongly hypointense). Pairwise comparison of lesion visibility between the two modalities was performed, and intermodality agreement was assessed.

RESULTS

On Kupffer-phase CEUS, 31 (20.1%) lesions were invisible, 17 (11.1%) were vaguely visible, and 106 (68.9%) were clearly visible. On the hepatobiliary-phase MRI, 9 (5.9%) lesions were invisible, 45 (29.2%) were vaguely visible, and 100 (64.9%) were clearly visible. Overall, lesion visibility scores were not significantly different between the two modalities (p = 0.121), but the visibility was significantly better on MRI in smaller lesions. Twenty-eight lesions (18.2%) showed discrepancy in the visibility on CEUS and MRI, and most of the cases (89.7%) were lesions that were invisible on CEUS but visible on MRI.

CONCLUSIONS

The overall visibility of FLLs was comparable between the Kupffer phase of Sonazoid-CEUS and the hepatobiliary-phase images of gadoxetic acid-enhanced MRI, with a discrepancy between the two modalities in 18% of the cases. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:542-550, 2017.

Efficacy of contrast-enhanced harmonic endoscopic ultrasonography in the diagnosis of pancreatic ductal carcinoma

BACKGROUND/AIMS

Distinguishing pancreatic ductal carcinoma (DC) from other pancreatic masses remains challenging. This study aims at evaluating the efficacy of contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) in the diagnosis of DC.

PATIENTS AND METHODS

Forty-nine patients with solid pancreatic mass lesions underwent CEH-EUS. EUS (B-mode) was used to evaluate the inner echoes, distributions, and borders of the masses. The vascular patterns of the masses were evaluated with CEH-EUS at 30-50 s (early phase) and 70-90 s (late phase) after the administration of Sonazoid®.

RESULTS

The final diagnoses included DCs (37), mass-forming pancreatitis (6), endocrine neoplasms (3), a solid pseudopapillary neoplasm (1), a metastatic carcinoma (1), and an acinar cell carcinoma (1). The sensitivity, specificity, and accuracy of the diagnoses of DC in hypoechoic masses using EUS (B-mode) were 89.2%, 16.7%, and 71.4%, respectively. The sensitivity, specificity, and accuracy for the diagnosis of DC in hypovascular masses using CEH-EUS were 73.0%, 91.7%, and 77.6% in the early phase and 83.8%, 91.7%, and 85.7% in the late phase, respectively.

CONCLUSIONS

CEH-EUS for the diagnosis of DC is superior to EUS. CEH-EUS in the late phase was particularly efficacious in the diagnosis of DC.

A case of sclerosing angiomatoid nodular transformation of the spleen: correlations between contrast-enhanced ultrasonography and histopathologic findings

Sclerosing angiomatoid nodular transformation (SANT) is a recently recognized benign vascular lesion of the spleen. Detection of SANT as an incidentaloma has increased due to improvements in imaging techniques. However, a definitive diagnosis of SANT on CT or MRI remains difficult. We report the use of contrast-enhanced ultrasonography with Sonazoid in a case of SANT in a 50-year-old woman, with gross and microscopic pathologic correlations.

Mucinous cystadenocarcinoma of the appendix in which contrast-enhanced ultrasonography was useful for assessing blood flow in a focal nodular lesion in the tumor cavity: A case report

A 63-year-old woman was admitted to hospital with pain in the right lower quadrant. Abdominal computed tomography (CT) revealed a 60-mm cystic mass at a site corresponding to the appendix. The mass wall on the appendicular ostium was thickened and enhanced by contrast, while calcification was observed in the mass wall on the appendicular tip. No projection was observed in the mass cavity. On abdominal ultrasonography (US), the mass wall on the appendicular ostium was thickened and projections were observed at two sites in the mass cavity. On contrast-enhanced US (CEUS), only one of these projections was enhanced. Based on the thickened and contrast-enhanced wall of the mass on the appendicular ostium on CT and US, as well as the contrast enhancement of a projection on US, the mass was diagnosed as mucinous cystadenocarcinoma of the appendix. Ileocecal resection was subsequently performed on day 10. A detailed examination of the surgical specimen revealed carcinoma cells in the mass wall on the appendicular ostium. The contrast-enhanced projection was identified as granulation tissue that had grown to come into contact with the tumor, while the non-contrast-enhanced projection was identified as solidified mucus. US enabled successful visualization of projections in the mass cavity that were not visible on abdominal CT. CEUS also proved useful for assessing blood flow in these projections.